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It is perhaps in the realisation that the current system of health overview and scrutiny committees, notwithstanding the time and effort that local authorities put into it, does not work to the satisfaction of everyone and could be a great deal better. At this moment when the Minister has put forward this document, which is I suppose a statement in time with aspirations for the future about how we are to improve the value of the NHS to health within local communities, this requirement to share on a more equal basis with local authorities the mechanisms for accountability should not be overly bureaucratic. People in the NHS should not be fearful of it, it is just one way of being more effective stewards of resources that may not diminish, but will be in increasing demand.
That is why we have tabled this amendment in this way and I hope that the Minister will find it acceptable. I beg to move.
Lord Walton of Detchant: Perhaps I may raise a note of caution in relation to this amendment, based upon historical experiences. One or two minor political points have been raised from both sides of the Committee and, as a Cross-Bencher, I do not take any political stance, as I am sure the Minister will appreciate.
However, I hark back to when I was a member of the Newcastle Regional Hospital Board in the late 1960s. In 1970 in Newcastle-upon-Tyne the board of governors of the Royal Victoria Infirmary, which had direct access to the Ministry of Health, as it then was, gave up its governors’ status and a new hospital management committee was created to embrace all the hospitals in Newcastle-upon-Tyne. It was a university hospital management committee made up of one-third university members, one-third health service staff of all grades and one-third from the local community. For three years, from 1971 to 1974, it functioned superbly.
Along came the Conservative Government, with Sir Keith Joseph—later Lord Joseph—as the Secretary of State for Health. On the basis of a report from the management consultancy firm McKinsey, he introduced a system of what he called “consensus management” in the National Health Service. That produced a system of district, area and regional health authorities. Consensus management resulted in a process whereby the decision-making machinery absolutely and totally congealed.
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The noble Lord, Lord Stoddart, who is not here, called for a Royal Commission on the National Health Service. In fact, a Royal Commission was established under the late Sir Alec Merrison and reported in 1980. It at last did something to sort out the appalling administrative mess resulting from those various actions. Since then, the reorganisation of the health service has been so much better, but I merely wish to strike a note of caution. There are now many members of local authorities who are non-executive directors of health bodies of various kinds and make an outstanding contribution, but I want to make it clear that that experience did not enamour me of the idea of major involvement of local authorities in the organisation of the NHS. It is right that they should be involved, but they should not dominate the bodies concerned with NHS delivery.
Baroness Cumberlege: I am in serious danger because I forgot to declare my interests—I may feature in the Guardian tomorrow. I should declare that I am an executive director of Cumberlege Connections Limited, which is an organisation that concentrates on training.
The noble Lord, Lord Walton, was talking about history. I remember chairing social services for a county council; I then became a district and regional health authority chair. In those days, I knew where the overlaps lay. I also knew where the voids between health and social services existed. I liked local government because it had a rigour about it. Knocking on 1,000 doors every four years is very salutary, especially when the resident goes in, reaches behind their clock, takes out your previous election manifesto and quizzes you on the promises that you made and broke.
The NHS lacks that rigour, that local democracy, and so it has to seek other mechanisms. It compensates for it with a whole cat’s cradle of different regulations of targets, accountabilities, standards, carrots and sticks. It needs that to ensure that it performs and that the Government can see where their public money is being spent.
My experience was a long time ago, but at the moment I am dealing weekly with local government and the NHS. I am not sure that an awful lot of
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As the noble Baroness, Lady Barker, said, we need to strengthen the accountability in the NHS; we need to strengthen joint working with social and social care services. The overview and scrutiny committees have been a brave attempt to do that. From talking to the people who have been before them and who have run them from local government, I believe that in some places they are really working very well. The local authority is thoughtful, knowledgeable and constructive in its criticism of the NHS. In other places, the local authorities have proved to be ill informed, overly political and destructive, and have jeopardised any sort of joint working. But this is early days. We have a lot to learn from each other, to spread good practice.
On commissioning, I think that the NHS has a lot to learn from local government, which embraced commissioning 25 years or so ago. I know that some joint commissioning is being trialled and I hope that will prove to be fruitful. However, I have a bit of a problem with the amendment. Although I absolutely support the intentions behind it, I am not sure about the last part of the amendment where it refers to,
It is the word “through” that could raise a lot of problems. I should be interested to hear the Minister’ reply to the amendment. I share the sentiment behind it, but it may not be quite the way forward.
6 pm
Baroness Young of Old Scone: Like the noble Baroness, Lady Cumberlege, I declare an interest as chair of the Care Quality Commission, which in 36 days will become the only regulator in the world covering both health and social care. I hope that it will be able to play a role in some of the issues that the noble Baroness raised.
On a technical point on the amendment proposed by the noble Baroness, Lady Barker, the list in Clause 2(2) contains two different sorts of organisations—first, providers of care on either a regional or a local basis and then, at the end, the two regulators, Monitor and the Care Quality Commission. It would be slightly strange if this requirement, which is really about local accountability and the local joining up of services, also caught up the two regulators in the process. That would probably need amendment. The regulatory bodies are established on a national basis to do their task—and it would probably be at odds with the Care Quality Commission’s role in particular in assessing the performance of local authorities on their adult and social care responsibilities.
I would not contest the principles that the noble Baroness, Lady Barker, is espousing of the need for drawing up close working arrangements at a local
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Lord Darzi of Denham: Amendment 11 would require all NHS bodies, including foundation trusts and special health authorities, Monitor and the Care Quality Commission to consult their local authority every year on the adequacy of their local accountability through their local councillors. I agree with the sentiment that it is vital for the NHS to engage with its local populations and with its key partners, such as local authorities. However, I do not believe that it is necessary to place such a requirement on the NHS. We have already introduced a comprehensive framework of policies, which I shall go through, to strengthen the accountability of the NHS. This includes giving councils the power to review and scrutinise local health services; introducing foundation trusts, with their membership systems; putting a legal duty on the NHS to involve local people in its decisions about services; and introducing local involvement networks. These reforms are backed up by the world-class commissioning programme, which holds primary care trusts to account for their performance, including how well they engage with their local population.
I distinctly remember the debate on this over the year when we put the constitution together. It is interesting to see my noble friend Lady Jay here, as she was also a member of a think tank as part of the King’s Fund, which was looking at the accountability of the NHS. It debated in significant breadth what the best model was.
The statement on NHS accountability, which was published alongside the NHS Constitution, shows that there are a number of ways in which PCTs are free to adopt local views, and I shall go through them again. They include: inviting local councillors or mayors on to their boards; increasing the integration of commissioned services through joint planning arrangements—there are numerous examples of joint commissioning; it is working well and we have seen the fruits of it; creating a local membership system; joint appointments of senior executives; formal partnership arrangements; and pooled budgets, which we will talk about in due course.
As the noble Baroness, Lady Barker, said, it is also critical that the public know how the NHS is accountable at a local level and how they can get involved in the accountability structure. That is why we set out very clearly some of the mechanisms that I described in the statement of NHS accountability, which, as I said, was published alongside the constitution. This is a public-facing document which explains roles, responsibilities and accountability in the NHS.
I think I have demonstrated that there is already an extensive system of local accountability in the NHS, and the NHS is of course always working to improve the way in which it involves local populations and works with local authorities. It is also not the case that the only mechanism for local accountability is through
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Baroness Barker: I thank noble Lords for their contributions to this debate. I start by assuring the noble Lord, Lord Walton, that it was not my intention in any way to reinvent the horrors of the 1970s, reconstituting effective bodies and replacing them with wholly ineffective ones. I had hoped that we were talking about something that reflected more the lessons of the past 30 years.
I absolutely do not underestimate how difficult it is to get the NHS and social care to work together effectively. Some people in both areas have spent their entire professional lives trying to make that happen with varying degrees of success, and some of them bear the scars. I certainly was not trying to advocate any kind of situation in which local councillors would be allowed to dominate health decisions. That would not be right. However, over the past 30 years we have come to recognise that for effective planning of health and social care services all sorts of people with professional knowledge—and, thinking about housing, in some cases technical knowledge—need to be involved on an equal basis in discussions with the policymakers.
I should like to ask the noble Lord, Lord Darzi, one question, although I do not expect him to come up with an answer instantly. How many PCTs invite councillors to be on their boards? I understand that there are examples of good practice but I should like to know how prevalent it is and how it works to good effect.
I accept some of the criticisms about some of the wording in the amendment. It was not an attempt on our part to say that local councillors are the only mechanism for local accountability; none the less, they are a pretty important one. I say to the noble Baroness, Lady Young of Old Scone, that we have had comprehensive area assessments for a long time and they have included health. These have recognised that we have had a health oversight and scrutiny committee but that it has not worked, so we need to move a bit further. I have long thought that one of the big problems in the NHS is that strategic health authorities do not relate to any other part of Government. Nevertheless, they exist and I accept that there is no appetite whatever anywhere in the NHS for a restructuring; you have to go with the structure as it is.
For all the flaws in the amendment’s wording, I was trying to dig out the fact that where health oversight and scrutiny committees see things going wrong and that the NHS is not having the impact that it should, they do not have a mechanism at the moment to influence strategic health authorities. That is a major gap. If strategic health authorities are to continue to have responsibility for the performance of PCTs, there has to be an alignment with social care.
I take entirely the point of the noble Baroness, Lady Cumberlege, that in social services people work to structures and that in the NHS they work to relationships. Happily, sometimes they come together—it
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There is a reason for introducing this provision now. I can remember that slightly more than 10 years ago, when resources were tight, social care and health services used to bat patients back and forward in order not to pick up responsibility for equipment, drugs or care. That kind of thing happens when money is tight. It is not yet tight, but it might be. If we can see a deficit—not in places for people to go and play at being local politicians—in the understanding of users of health and social care services of how the resources are being used in their area, addressing that situation now would be very wise.
I have listened to the Minister and to the comments made by other noble Lords about the deficiency of the wording. I shall take the amendment away but I may wish to return to the issue in some respects. I beg leave to withdraw the amendment.
Baroness Barker: I shall speak also to Amendments 16, 21 and 31. This group of amendments is on a similar tack. It concerns the list of bodies that are to be consulted when the NHS constitution is revised 10 years hence. There is a presumption that the bodies listed will still be around and functioning, but that may be dreadfully optimistic given the lifespan of some NHS bodies over the past few years. None the less, the amendments in the group highlight the concern shared by noble Lords around the Committee that if the document is to work in the way envisaged by the Minister, it needs to be, if nothing else, a focal point for discussion about how the NHS is working and should work in the future, and a number of people ought to be involved as of right, separately and distinctly, in any revision of it. Carers, for example, should not be swept up in a general category of “the public” because they have a distinct input.
I cannot stress enough that local authorities and representative bodies of local authorities should be involved. We will move to a time when responsibility for health will go well beyond the National Health Service and on to what remains of the public service infrastructure. If this document takes off and becomes the progressive tool that the Minister envisages, then he has nothing to fear in stating publicly now that these groups of people will be involved in its revision as it goes on with its life. I beg to move.
6.15 pm
Earl Howe: I shall speak to the amendments in this group that are tabled in my name, Amendments 14, 15, 17, 19 and 20. One of the surprising features of an
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We see in Clause 3 that provision is made for the Secretary of State to undertake a consultation before revising the constitution. That is fine until we look a little further on and see how limited is the nature of that consultation. Nowhere is there a mention of carers; patients are mentioned but not bodies representing patients or particular groups of patients; and there is no mention of local involvement networks, the bodies created by the Government only last year to act as local patient watchdogs. I would like to see mention made of bodies that represent staff, such as the BMA, the RCN and the other unions—not just, say, a handful of random NHS employees.
At the end of the consultation exercise, what does the Secretary of State have to do by way of publishing the results of the consultation? Absolutely nothing. He can review and revise the constitution without having to disclose to anyone what feedback he has received, so that it will be impossible for any of us to know to what extent he has taken account of the comments made to him. It is a closed process, and that surely cannot be right.
There are two reasons why that is not satisfactory. The first relates to specialised services, which got a raw deal in the NHS Constitution; they are not even mentioned. There is a paragraph on page 15 of the handbook about the existence of specialised services, but couched in terms that grossly belittle their importance:
“The NHS also provides access to ‘specialised services’ for the small number of people”—
- “who suffer from rare conditions. These specialised services are commissioned either regionally or nationally from a few specialist centres, depending on the rarity of the condition or treatment”.
Given that specialised services account for no less than 10 per cent of the NHS budget and many hundreds of thousands of NHS patients, often in the most extreme need, this seems to be—to put it mildly—inadequate recognition. The constitution itself, not just the handbook, should enshrine the importance of regional and supra-regional services alongside local planning and provision. It is, after all, this combination of local, regional and supra-regional that makes the NHS a truly national service.
The second reason why this part of the Bill is unsatisfactory is the absence of any acknowledgment of patient and public involvement in decision-making. A number of organisations have pointed that out, including the BMA, RADAR and the RCN. Patient and public involvement is mentioned in the constitution, which is well and good, but there is no provision in this clause for involvement by LINks or bodies like the Patients Association in providing feedback on the drafting of what is intended to be a key point of reference for the delivery of health services. It is difficult to involve everyone in a dialogue, but if the Secretary of State were to have an explicit obligation to publish a report setting out the results of the consultation, it
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One group that feels short-changed is the disabled. RADAR has made clear its disappointment that the opportunity was not seized during the drafting of the constitution to highlight the full nature of existing rights under the Disability Discrimination Act in relation to equality of access to health services and to treatment. Neither the constitution nor the handbook refers explicitly to the right to reasonable adjustments for disabled people, which is a key provision of the DDA. All that the documents mention is the right not to be treated less favourably on various grounds, which is not at all the same thing. It would have been very helpful if, at the very least, the handbook could have given clear information about the statutory duties that exist to promote disability, race and gender equality. We know that there are large inequalities in access to primary care on the part of people with mental health problems and people with learning disabilities. A reminder to PCTs about the need to tackle those would not have gone amiss.
I shall say a brief word about carers. Carers engage with the NHS in a completely different way from either patients or ordinary members of the public. Very often, it is carers who facilitate access to services on behalf of the patients they look after, and their own lives are almost as much affected by the quality of those services as those who are in receipt of them. As a result, they bring a different perspective on how well or how badly the NHS is meeting patients’ needs. As the Minister will know, that valuable difference is recognised in other contexts, where health bodies are required to consult and involve carers. The NHS operating framework for 2009-10 says that PCTs must devisejoint plans with local authorities to provide carers with breaks. The Putting People First concordat between the NHS and local government recognises that family members and carers are to be treated as experts and partners in the delivery of care. There is a strong case for seeking the views of carers whenever the NHS constitution is being reviewed or revised. I should add that I am very much in support of Amendment 31 of the noble Baroness, Lady Tonge, which says that the three-yearly report on the practical effect of the constitution should include a report on how it has affected carers.
Baroness Pitkeathley: Your Lordships will not be surprised that I rise to speak in support of the amendments about carers—that is, Amendments 16, 20 and 31. Not including carers in this matter is a missed opportunity. That is strange for this Government, who have an exemplary record as far as carers are concerned, which I acknowledge. I declare an interest as vice-president of Carers UK and president of Eurocarers. In those roles, I am well aware that what this Government have done for carers is the envy of the world. We have only to look at the national strategy, the Standing Commission on Carers, Acts of Parliament and the kind of regulations and encouragements which the noble Earl, Lord Howe, has already mentioned to us. It is a missed opportunity if we do not mention them specifically in this regard.
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